PA 05-196—sSB 508
Insurance and Real Estate Committee
Public Health Committee
AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR INFERTILITY TREATMENT AND PROCEDURES
SUMMARY: This act requires individual and group health insurance policies to cover the medically necessary costs of diagnosing and treating infertility. It specifies permissible coverage limitations and requirements. It also permits religious employers and individuals to exclude infertility coverage if it is contrary to their religious tenets. Prior law required insurers and HMOs to offer infertility coverage to group plan sponsors, who could have rejected or accepted it.
The act requires a clinical practice that performs insurance-covered in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), or zygote intra-fallopian transfer (ZIFT) procedures to report certain information to the Department of Public Health (DPH) by February 1 following any year it performs the procedures.
The act applies to policies delivered, issued, amended, renewed, or continued on and after October 1, 2005 that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including HMOs.
EFFECTIVE DATE: October 1, 2005
The act requires health insurance policies to cover medically necessary expenses incurred for the diagnosis and treatment of infertility, including ovulation induction, intrauterine insemination, IVF, uterine embryo lavage, embryo transfer, GIFT, ZIFT, and low tubal ovum transfer. It defines “infertility” as the inability of a presumably healthy person to conceive or produce conception or sustain a successful pregnancy during a one-year period.
COVERAGE LIMITATIONS AND REQUIREMENTS
A policy can:
1. limit coverage to people under age 40;
2. place a lifetime ovulation induction coverage limit of four cycles;
3. place a lifetime intrauterine insemination coverage limit of three cycles;
4. place a lifetime IVF, GIFT, ZIFT, or low tubal ovum transfer limit of two cycles and two embryo implantations per cycle, where each fertilization and transfer procedure counts toward the maximum as one cycle;
5. require covered services to be performed at facilities conforming to standards and guidelines developed by the American Society for Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility;
6. limit coverage to people who have been covered by the policy for at least 12 months;
7. require a person seeking infertility coverage to disclose to the insurer on a form developed by the insurance commissioner any previous infertility treatment or procedures for which a different health insurance policy provided coverage; and
8. limit IVF, GIFT, ZIFT, and low tubal ovum transfers to people who have used less expensive and medically viable treatments or procedures covered under the policy but remain infertile.
But, coverage for IVF, GIFT, ZIFT, and low tubal ovum transfers cannot be denied if a person forgoes a less expensive treatment option because her doctor determines it is unlikely to be successful.
An insurer, medical or service corporation, or HMO can issue a religious employer a health insurance policy that excludes infertility diagnosis and treatment coverage contrary to the employer's bona fide religious tenets.
If a person states in writing that infertility diagnosis and treatment is contrary to his religious or moral beliefs, an insurer, medical or service corporation, or HMO can issue him a policy or rider that excludes the coverage.
An entity that issues a policy excluding the infertility coverage because of the religious exemption must give written notice of the exclusion to each insured or prospective insured. The notice must appear in the policy, application, and sales brochure and be in at least 10-point type.
Under the act, a “religious employer” is a “qualified church-controlled organization,” as defined in federal law, or a church-affiliated organization. Federal law defines “qualified church-controlled organization” as a church-controlled tax-exempt organization, other than one that (1) offers goods, services, or facilities for sale to the general public, other than those sold at a nominal charge that is substantially less than the actual cost, and (2) normally receives more than 25% of its support from either (a) government sources or (b) receipts from admissions, merchandise sales, services performed, or facilities furnished (26 USC § 3121).
A clinical practice that performs insurance-covered IVF, GIFT, and ZIFT procedures must report to DPH by February 1 the (1) number of procedures performed the previous year; (2) number of multiple births or conceptions per pregnancy with a breakdown of births or conceptions per pregnancy; and (3) rates of complications. It must also report, per patient on average and by the number of attempts required, the (1) number of procedures attempted before a successful implantation, (2) number of embryos implanted, and (3) pregnancy rate. The practice must report the information on a form DPH develops.
Ovulation induction uses medication to stimulate development of one or more mature follicles (where eggs develop) in a woman’s ovaries. IVF uses a drug to stimulate a woman’s egg production. Once mature, the eggs are removed to a culture dish and fertilized with sperm. After fertilization, embryos are placed in the woman’s uterus.
In GIFT, egg and sperm are placed in a woman’s fallopian tubes where fertilization can occur naturally. ZIFT involves placing embryos in a woman’s fallopian tubes. Low tubal ovum transfer involves transferring eggs past a blocked or damaged section of the fallopian tube to an area closer to the uterus. Uterine embryo lavage is a procedure by which the uterus is flushed to recover a preimplantation embryo from a donor and then transferring it to the woman who is to bear the child.